3D bioprinting for lung and tracheal tissue engineering: Criteria, advances, challenges, and future directions

Advanced 3D In Vitro Lung Fibrosis Models: Contemporary Status, Clinical Uptake, and Prospective Outlooks

Fibrosis has been characterized as a global health problem and ranks as one of the primary causes of organ dysfunction. Currently, there is no cure for pulmonary fibrosis, and limited therapeutic options are available due to an inadequate understanding of the disease pathogenesis. The absence of advanced in vitro models replicating dynamic temporal changes observed in the tissue with the progression of the disease is a significant impediment in the development of novel antifibrotic treatments, which has motivated research on tissue-mimetic three-dimensional (3D) models. In this review, we summarize emerging trends in preparing advanced lung models to recapitulate biochemical and biomechanical processes associated with lung fibrogenesis. We begin by describing the importance of in vivo studies and highlighting the often poor correlation between preclinical research and clinical outcomes and the limitations of conventional cell culture in accurately simulating the 3D tissue microenvironment. Rapid advancement in biomaterials, biofabrication, biomicrofluidics, and related bioengineering techniques are enabling the preparation of in vitro models to reproduce the epithelium structure and operate as reliable drug screening strategies for precise prediction. Improving and understanding these model systems is necessary to find the cross-talks between growing cells and the stage at which myofibroblasts differentiate. These advanced models allow us to utilize the knowledge and identify, characterize, and hand pick medicines beneficial to the human community. The challenges of the current approaches, along with the opportunities for further research with potential for translation in this field, are presented toward developing novel treatments for pulmonary fibrosis.

Organ bioprinting: progress, challenges and outlook

Bioprinting, as a groundbreaking technology, enables the fabrication of biomimetic tissues and organs with highly complex structures, multiple cell types, mechanical heterogeneity, and diverse functional gradients. With the growing demand for organ transplantation and the limited number of organ donors, bioprinting holds great promise for addressing the organ shortage by manufacturing completely functional organs. While the bioprinting of complete organs remains a distant goal, there has been considerable progress in the development of bioprinted transplantable tissues and organs for regenerative medicine. This review article recapitulates the current achievements of organ 3D bioprinting, primarily encompassing five important organs in the human body (i.e., the heart, kidneys, liver, pancreas, and lungs). Challenges from cellular techniques, biomanufacturing technologies, and organ maturation techniques are also deliberated for the broad application of organ bioprinting. In addition, the integration of bioprinting with other cutting-edge technologies including machine learning, organoids, and microfluidics is envisioned, which strives to offer the reader the prospect of bioprinting in constructing functional organs.

Advanced imaging and modeling in neonatal simulation

Advances in modeling and imaging have resulted in realistic tools that can be applied to education and training, and even direct patient care. These include point-of-care ultrasound (POCUS), 3-dimensional and digital anatomic modeling, and extended reality. These technologies have been used for the preparation of complex patient care through simulation-based clinical rehearsals, direct patient care such as the creation of patient devices and implants, and for simulation-based education and training for health professionals, patients and families. In this section, we discuss these emerging technologies and describe how they can be utilized to improve patient care.

Classification, processing, and applications of bioink and 3D bioprinting: A detailed review

With the advancement in 3D bioprinting technology, cell culture methods can design 3D environments which are both, complex and physiologically relevant. The main component in 3D bioprinting, bioink, can be split into various categories depending on the criterion of categorization. Although the choice of bioink and bioprinting process will vary greatly depending on the application, general features such as material properties, biological interaction, gelation, and viscosity are always important to consider. The foundation of 3D bioprinting is the exact layer-by-layer implantation of biological elements, biochemicals, and living cells with the spatial control of the implantation of functional elements onto the biofabricated 3D structure. Three basic strategies underlie the 3D bioprinting process: autonomous self-assembly, micro tissue building blocks, and biomimicry or biomimetics. Tissue engineering can benefit from 3D bioprinting in many ways, but there are still numerous obstacles to overcome before functional tissues can be produced and used in clinical settings. A better comprehension of the physiological characteristics of bioink materials and a higher level of ability to reproduce the intricate biologically mimicked and physiologically relevant 3D structures would be a significant improvement for 3D bioprinting to overcome the limitations.

(Bio)printing in Personalized Medicine—Opportunities and Potential Benefits

The global development of technologies now enters areas related to human health, with a transition from conventional to personalized medicine that is based to a significant extent on (bio)printing. The goal of this article is to review some of the published scientific literature and to highlight the importance and potential benefits of using 3D (bio)printing techniques in contemporary personalized medicine and also to offer future perspectives in this research field. The article is prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Web of Science, PubMed, Scopus, Google Scholar, and ScienceDirect databases were used in the literature search. Six authors independently performed the search, study selection, and data extraction. This review focuses on 3D bio(printing) in personalized medicine and provides a classification of 3D bio(printing) benefits in several categories: overcoming the shortage of organs for transplantation, elimination of problems due to the difference between sexes in organ transplantation, reducing the cases of rejection of transplanted organs, enhancing the survival of patients with transplantation, drug research and development, elimination of genetic/congenital defects in tissues and organs, and surgery planning and medical training for young doctors. In particular, we highlight the benefits of each 3D bio(printing) applications included along with the associated scientific reports from recent literature. In addition, we present an overview of some of the challenges that need to be overcome in the applications of 3D bioprinting in personalized medicine. The reviewed articles lead to the conclusion that bioprinting may be adopted as a revolution in the development of personalized, medicine and it has a huge potential in the near future to become a gold standard in future healthcare in the world.

What is the need and why is it time for innovative models for understanding lung repair and regeneration?

Advances in tissue engineering continue at a rapid pace and have provided novel methodologies and insights into normal cell and tissue homeostasis, disease pathogenesis, and new potential therapeutic strategies. The evolution of new techniques has particularly invigorated the field and span a range from novel organ and organoid technologies to increasingly sophisticated imaging modalities. This is particularly relevant for the field of lung biology and diseases as many lung diseases, including chronic obstructive pulmonary disease (COPD) and idiopathic fibrosis (IPF), among others, remain incurable with significant morbidity and mortality. Advances in lung regenerative medicine and engineering also offer new potential avenues for critical illnesses such as the acute respiratory distress syndrome (ARDS) which also continue to have significant morbidity and mortality. In this review, an overview of lung regenerative medicine with focus on current status of both structural and functional repair will be presented. This will serve as a platform for surveying innovative models and techniques for study, highlighting the need and timeliness for these approaches.

Bioengineering lungs: An overview of current methods, requirements, and challenges for constructing scaffolds

Chronic respiratory diseases remain a significant health burden worldwide. The only option for individuals with end-stage lung failure remains Lung Transplantation. However, suitable organ donor shortages and immune rejection following transplantation remain a challenge. Since alternative options are urgently required to increase tissue availability for lung transplantation, researchers have been exploring lung bioengineering extensively, to generate functional, transplantable organs and tissue. Additionally, the development of physiologically-relevant artificial tissue models for testing novel therapies also represents an important step toward finding a definite clinical solution for different chronic respiratory diseases. This mini-review aims to highlight some of the most common methodologies used in bioengineering lung scaffolds, as well as the benefits and disadvantages associated with each method in conjunction with the current areas of research devoted to solving some of these challenges in the area of lung bioengineering.

Recent advances in 3D-printed polylactide and polycaprolactone-based biomaterials for tissue engineering applications

The three-dimensional printing (3DP) also known as the additive manufacturing (AM), a novel and futuristic technology that facilitates the printing of multiscale, biomimetic, intricate cytoarchitecture, function-structure hierarchy, multi-cellular tissues in the complicated micro-environment, patient-specific scaffolds, and medical devices. There is an increasing demand for developing 3D-printed products that can be utilized for organ transplantations due to the organ shortage. Nowadays, the 3DP has gained considerable interest in the tissue engineering (TE) field. Polylactide (PLA) and polycaprolactone (PCL) are exemplary biomaterials with excellent physicochemical properties and biocompatibility, which have drawn notable attraction in tissue regeneration. Herein, the recent advancements in the PLA and PCL biodegradable polymer-based composites as well as their reinforcement with hydrogels and bio-ceramics scaffolds manufactured through 3DP are systematically summarized and the applications of bone, cardiac, neural, vascularized and skin tissue regeneration are thoroughly elucidated. The interaction between implanted biodegradable polymers, in-vivo and in-vitro testing models for possible evaluation of degradation and biological properties are also illustrated. The final section of this review incorporates the current challenges and future opportunities in the 3DP of PCL- and PLA-based composites that will prove helpful for biomedical engineers to fulfill the demands of the clinical field.

Bone Marrow Derived Mesenchymal Stromal Cells Promote Vascularization and Ciliation in Airway Mucosa Tri-Culture Models in Vitro

Patients suffering from irresectable tracheal stenosis often face limited treatment options associated with low quality of life. To date, an optimal tracheal replacement strategy does not exist. A tissue-engineered tracheal substitute promises to overcome limitations such as implant vascularization, functional mucociliary clearance and mechanical stability. In order to advance a tracheal mucosa model recently developed by our group, we examined different supporting cell types in fibrin-based tri-culture with primary human umbilical vein endothelial cells (HUVEC) and primary human respiratory epithelial cells (HRE). Bone marrow-derived mesenchymal stromal cells (BM-MSC), adipose-derived mesenchymal stromal cells (ASC) and human nasal fibroblasts (HNF) were compared regarding their ability to promote mucociliary differentiation and vascularization in vitro. Three-dimensional co-cultures of the supporting cell types with either HRE or HUVEC were used as controls. Mucociliary differentiation and formation of vascular-like structures were analyzed by scanning electron microscopy (SEM), periodic acid Schiff’s reaction (PAS reaction), two-photon laser scanning microscopy (TPLSM) and immunohistochemistry. Cytokine levels of vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), interleukin-6 (IL6), interleukin-8 (IL8), angiopoietin 1, angiopoietin 2, fibroblast growth factor basic (FGF-b) and placenta growth factor (PIGF) in media supernatant were investigated using LEGENDplex™ bead-based immunoassay. Epithelial morphology of tri-cultures with BM-MSC most closely resembled native respiratory epithelium with respect to ciliation, mucus production as well as expression and localization of epithelial cell markers pan-cytokeratin, claudin-1, α-tubulin and mucin5AC. This was followed by tri-cultures with HNF, while ASC-supported tri-cultures lacked mucociliary differentiation. For all supporting cell types, a reduced ciliation was observed in tri-cultures compared to the corresponding co-cultures. Although formation of vascular-like structures was confirmed in all cultures, vascular networks in BM-MSC-tri-cultures were found to be more branched and extended. Concentrations of pro-angiogenic and inflammatory cytokines, in particular VEGF and angiopoietin 2, revealed to be reduced in tri-cultures compared to co-cultures. With these results, our study provides an important step towards a vascularized and ciliated tissue-engineered tracheal replacement. Additionally, our tri-culture model may in the future contribute to an improved understanding of cell-cell interactions in diseases associated with impaired mucosal function.

Dityrosine-inspired photocrosslinking technique for 3D printing of silk fibroin-based composite hydrogel scaffolds

Photoinduced self-crosslinking technology is a great facilitator of 3D bioprinting of silk fibroin (SF) by allowing rapid solidification of a deliberately formulated SF-based photocrosslinkable bioink. An SF-based, photocrosslinked hydrogel was fabricated with tyramine-modified sodium carboxymethyl cellulose (CMC-Na) as a co-crosslinkable constituent and Ru(bpy)₃Cl₂ (Ru(II)) and potassium persulfate (KPS) as blue light photoinitiators. Photorheological studies demonstrated that the photocrosslinking and viscoelasticity of the composite could be tuned by varying the relative content of the two constituents. Xanthan gum (XG) was employed in formulating the SF-based photocrosslinkable bioink, and the improved rheological properties and printability were evidenced by the resulting tunable shear-thinning behavior and shear thixotropy. 3D SF-based hydrogel scaffolds with uniform pores with a size of approximately 550 μm × 1000 μm were constructed via extrusion-based printing and a simple 30 s post-photocrosslinking combined process. Furthermore, the CMC-Na incorporated 3D hydrogel scaffolds exhibited sufficient structural strength, adequate filament fineness, and tunable transparency, which shows a promising prospect in the application of tissue engineering and regenerative medicine.

3D Bioprinting of Human Hollow Organs

3D bioprinting is a rapidly evolving technique that has been found to have extensive applications in disease research, tissue engineering, and regenerative medicine. 3D bioprinting might be a solution to global organ shortages and the growing aversion to testing cell patterning for novel tissue fabrication and building superior disease models. It has the unrivaled capability of layer-by-layer deposition using different types of biomaterials, stem cells, and biomolecules with a perfectly regulated spatial distribution. The tissue regeneration of hollow organs has always been a challenge for medical science because of the complexities of their cell structures. In this mini review, we will address the status of the science behind tissue engineering and 3D bioprinting of epithelialized tubular hollow organs. This review will also cover the current challenges and prospects, as well as the application of these complicated 3D-printed organs.

Three-dimensional models of the lung: past, present and future: a mini review

Respiratory diseases are a major reason for death in both men and women worldwide. The development of therapies for these diseases has been slow and the lack of relevant human models to understand lung biology inhibits therapeutic discovery. The lungs are structurally and functionally complex with many different cell types which makes designing relevant lung models particularly challenging. The traditional two-dimensional (2D) cell line cultures are, therefore, not a very accurate representation of the in vivo lung tissue. The recent development of three-dimensional (3D) co-culture systems, popularly known as organoids/spheroids, aims to bridge the gap between 'in-dish' and 'in-tissue' cell behavior. These 3D cultures are modeling systems that are widely divergent in terms of culturing techniques (bottom-up/top-down) that can be developed from stem cells (adult/embryonic/pluripotent stem cells), primary cells or from two or more types of cells, to build a co-culture system. Lung 3D models have diverse applications including the understanding of lung development, lung regeneration, disease modeling, compound screening, and personalized medicine. In this review, we discuss the different techniques currently being used to generate 3D models and their associated cellular and biological materials. We further detail the potential applications of lung 3D cultures for disease modeling and advances in throughput for drug screening.

Cell-Seeded Biomaterial Scaffolds: The Urgent Need for Unanswered Accelerated Angiogenesis

One of the most arduous challenges in tissue engineering is neovascularization, without which there is a lack of nutrients delivered to a target tissue. Angiogenesis should be completed at an optimal density and within an appropriate period of time to prevent cell necrosis. Failure to meet this challenge brings about poor functionality for the tissue in comparison with the native tissue, extensively reducing cell viability. Prior studies devoted to angiogenesis have provided researchers with some biomaterial scaffolds and cell choices for angiogenesis. For example, while most current angiogenesis approaches require a variety of stimulatory factors ranging from biomechanical to biomolecular to cellular, some other promising stimulatory factors have been underdeveloped (such as electrical, topographical, and magnetic). When it comes to choosing biomaterial scaffolds in tissue engineering for angiogenesis, key traits rush to mind including biocompatibility, appropriate physical and mechanical properties (adhesion strength, shear stress, and malleability), as well as identifying the appropriate biomaterial in terms of stability and degradation profile, all of which may leave essential trace materials behind adversely influencing angiogenesis. Nevertheless, the selection of the best biomaterial and cells still remains an area of hot dispute as such previous studies have not sufficiently classified, integrated, or compared approaches. To address the aforementioned need, this review article summarizes a variety of natural and synthetic scaffolds including hydrogels that support angiogenesis. Furthermore, we review a variety of cell sources utilized for cell seeding and influential factors used for angiogenesis with a concentrated focus on biomechanical factors, with unique stimulatory factors. Lastly, we provide a bottom-to-up overview of angiogenic biomaterials and cell selection, highlighting parameters that need to be addressed in future studies.

The Patent Eligibility of 3D Bioprinting: Towards a New Version of Living Inventions’ Patentability

A combination of 3D printing techniques and synthetic biology, 3D bioprinting is a promising field. It is expected that 3D bioprinting technologies will have applications across an array of fields, spanning biotechnology, medical surgery and the pharmaceutical industry. Nonetheless, the progress of these technologies could be hindered, unless there is adequate and effective protection for related applications. In this article, the authors examine the patent eligibility of 3D bioprinting technologies. This issue raises concern given that existing patent systems are generally averse to nature-derived inventions and many of them exclude products of nature or discoveries from patentability. This qualitative study analyses the current patent systems in key jurisdictions, particularly, the U.S. and the EU, and their applicability, as well as effectiveness, in the context of 3D bioprinting. The study argues that the main reason for the apathy of existing patent systems towards bio-inventions is that they were designed to deal with mechanical inventions. It suggests an innovation framework that encompasses both mechanical and biological inventions to cater adequately to emerging technologies.

Novel Digital Light Processing Printing Strategy Using a Collagen-Based Bioink with Prospective Cross-Linker Procyanidins

Three-dimensional (3D) bioink plays a vital role in the construction of tissues and organs by 3D bioprinting. Collagen has outstanding biocompatibility and is widely used in the field of tissue engineering. However, due to poor mechanical properties and slow self-assembly, it is challenging to manufacture high-precision 3D bioprinted collagen scaffolds. Herein, a novel digital light processing (DLP) bioink which can satisfy the printing of complex structures has been developed. This photocurable bioink is based on collagen and supplemented with a small amount of procyanidins (PA) as a cross-linking agent. The low concentration of collagen gives the bioink good fluidity and excellent biocompatibility, and a small amount of PA increases the cross-linking density of the system to obtain better mechanical properties. Using commercial digital light processing (DLP) printers, this collagen-based ink can effectively print structures with micrometer resolution, and the fidelity of the 3D structures can reach above 90%. Cells were able to be loaded in the bioink and distributed uniformly in the collagen scaffold in an unscathed way. This photocurable collagen bioink has broad application potential in DLP 3D bioprinting.

Additive Manufacturing of Biopolymers for Tissue Engineering and Regenerative Medicine: An Overview, Potential Applications, Advancements, and Trends

As a technique of producing fabric engineering scaffolds, three-dimensional (3D) printing has tremendous possibilities. 3D printing applications are restricted to a wide range of biomaterials in the field of regenerative medicine and tissue engineering. Due to their biocompatibility, bioactiveness, and biodegradability, biopolymers such as collagen, alginate, silk fibroin, chitosan, alginate, cellulose, and starch are used in a variety of fields, including the food, biomedical, regeneration, agriculture, packaging, and pharmaceutical industries. The benefits of producing 3D-printed scaffolds are many, including the capacity to produce complicated geometries, porosity, and multicell coculture and to take growth factors into account. In particular, the additional production of biopolymers offers new options to produce 3D structures and materials with specialised patterns and properties. In the realm of tissue engineering and regenerative medicine (TERM), important progress has been accomplished; now, several state-of-the-art techniques are used to produce porous scaffolds for organ or tissue regeneration to be suited for tissue technology. Natural biopolymeric materials are often better suited for designing and manufacturing healing equipment than temporary implants and tissue regeneration materials owing to its appropriate properties and biocompatibility. The review focuses on the additive manufacturing of biopolymers with significant changes, advancements, trends, and developments in regenerative medicine and tissue engineering with potential applications.

Decellularized human-sized pulmonary scaffolds for lung tissue engineering: a comprehensive review

The ultimate goal of lung bioengineering is to produce transplantable lungs for human beings. Therefore, large-scale studies are of high importance. In this paper, we review the investigations on decellularization and recellularization of human-sized lung scaffolds. First, studies that introduce new ways to enhance the decellularization of large-scale lungs are reviewed, followed by the investigations on the xenogeneic sources of lung scaffolds. Then, decellularization and recellularization of diseased lung scaffolds are discussed to assess their usefulness for tissue engineering applications. Next, the use of stem cells in recellularizing acellular lung scaffolds is reviewed, followed by the case studies on the transplantation of bioengineered lungs. Finally, the remaining challenges are discussed, and future directions are highlighted.

Immune response against the biomaterials used in 3D bioprinting of organs

Regenerative medicine has developed promising approaches for healing and replacing defective and damaged organs or tissues with functional ones. Three-dimensional (3D) bioprinting innovation has integrated a potential to design organs or tissues specific to the patient with the capability of rapid construction to fulfill the storage of organs and the need for transplantation. 3D bioprinting of organs has the main goal to develop a structural and functional organ or tissue mimic to the original one. The highly complex fabrication of tissue engineering scaffolds containing biomaterials, tissue models, and biomedical devices has made it possible to print small blood vessels to mimic organs to reduce organ or tissue rejection. 3D bioprinting has the concept of bioinks containing biomaterials that may trigger the immune responses in the body. Nevertheless, foreign body response (FBR) is mediated by various cell types such as B-cells, dendritic cells, macrophages, natural killer cells, neutrophils, and T-cells, and molecular signals such as antibodies (Abs), cytokines, and reactive radical species. Typically, the biomaterial is shielded by the fibrous encapsulation that is regulated by molecular signals. This review explored the progress in 3D bioprinting of vital organs and basic immune response against the biomaterials used in this approach. Thus, evaluating immune response against biomaterials used in 3D printed organs is necessary to mitigate tissue rejection after the transplantation.

Enhanced articular cartilage decellularization using a novel perfusion-based bioreactor method

Current decellularization methods for articular cartilages require many steps, various and high amounts of detergents, and a relatively long time to produce decellularized scaffolds. In addition, such methods often damage the essential components and the structure of the tissue. This study aims to introduce a novel perfusion-based bioreactor (PBB) method to decellularize bovine articular cartilages efficiently while reducing the harmful physical and chemical steps as well as the duration of the process. This leads to better preservation of the structure and the essential components of the native tissue. Firstly, a certain number of channels (Ø 180 μm) were introduced into both sides of cylindrical articular bovine cartilage disks (5 mm in diameter and 1 mm in thickness). Next, the disks were decellularized in the PBB and a shaker as the control. Using the PBB method resulted in ∼90% reduction of DNA content in the specimens, which was significantly higher than those of the shaker results with ∼60%. Also, ∼50% sulfated glycosaminoglycan (sGAG) content and ∼92% of the compression properties were maintained implying the efficient preservation of the structure and components of the scaffolds. Moreover, the current study indicated that the PBB specimens supported the adherence and proliferation of the new cells effectively. In conclusion, the results show that the use of PBB method increases the efficiency of producing decellularized cartilage scaffolds with a better maintenance of essential components and structure, while reducing the chemicals and steps required for the process. This will pave the way for producing close-to-natural scaffolds for cartilage tissue engineering.

Advances in bioreactors for lung bioengineering: From scalable cell culture to tissue growth monitoring

Lung bioengineering has emerged to resolve the current lung transplantation limitations and risks, including the shortage of donor organs and the high rejection rate of transplanted lungs. One of the most critical elements of lung bioengineering is bioreactors. Bioreactors with different applications have been developed in the last decade for lung bioengineering approaches, aiming to produce functional reproducible tissue constructs. Here, the current status and advances made in the development and application of bioreactors for bioengineering lungs are comprehensively reviewed. First, bioreactor design criteria are explained, followed by a discussion on using bioreactors as a culture system for scalable expansion and proliferation of lung cells, such as producing epithelial cells from induced pluripotent stem cells (iPSCs). Next, bioreactor systems facilitating and improving decellularization and recellularization of lung tissues are discussed, highlighting the studies that developed bioreactors for producing engineered human-sized lungs. Then, monitoring bioreactors are reviewed, showing their ability to evaluate and optimize the culture conditions for maturing engineered lung tissues, followed by an explanation on the ability of ex vivo lung perfusion systems for reconditioning the lungs before transplantation. After that, lung cancer studies simplified by bioreactors are discussed, showing the potentials of bioreactors in lung disease modeling. Finally, other platforms with the potential of facilitating lung bioengineering are described, including the in vivo bioreactors and lung-on-a-chip models. In the end, concluding remarks and future directions are put forward to accelerate lung bioengineering using bioreactors.